Undetected Cognitive Impairment Research Articles

Relationship Between Cognitive Impairment and Depression Among Middle Aged and Older Adults in Primary Care.

Objectives: To determine rates of previously undetected cognitive impairment among patients with depression in primary care. Methods: Patients ages 55 and older with no documented history of dementia or mild cognitive impairment were recruited from primary care practices in New York City, NY and Chicago, IL (n = 855). Cognitive function was assessed with the Montreal Cognitive Assessment (MoCA) and depression with the Patient Health Questionnaire-8. Results: The mean age was 66.8 (8.0) years, 45.3% were male, 32.7% Black, and 29.2% Latinx. Cognitive impairment increased with severity of depression: 22.9% in persons with mild depression, 27.4% in moderate depression and 41.8% in severe depression (p = .0002). Severe depression was significantly associated with cognitive impairment in multivariable analysis (standardized β = -.11, SE = 0.33, p < .0001). Discussion: Depression was strongly associated with previously undetected cognitive impairment. Primary care clinicians should consider screening, or expand their screening, for both conditions.

Early identification of cognitive impairment among vulnerable older adults living at home

AbstractBackgroundAfrican Americans are twice as likely as Caucasians to develop Alzheimer’s Disease and Related Dementias (AD/ADRD) and less likely to seek a diagnosis before experiencing a crisis. This study evaluated the impact of adding Mini‐Cog© screenings to Area Agency on Aging (AAA) assessments on early detection of cognitive impairment among low‐income older adults.MethodMini‐Cog™ assessments were offered to new and existing clients of a AAA Neighborhood Advisor. Clients with scores indicating impairment were referred to an academic geriatric practice for comprehensive evaluation. Inclusion criteria were age 65 or older, English speaking, living at home in the Advisor’s service area, and not previously diagnosed as AD/ADRD. Data collected over 9 months included Mini‐Cog™ scores, age, race, ethnicity, and geriatric referrals. Quantitative analysis included bivariate descriptive statistics (significance alpha of .10) and simple linear regression (significance alpha of .05).ResultsOf 69 study participants, 84% were female, 54% African American, and 93% non‐Hispanic. Mean age was 74.7 years and mean Mini‐Cog™ score was 3.61 (range: 0‐5). Independent t‐tests show that African American participants had lower Mini‐Cog™ scores than Caucasians (3.35±.23 vs 3.91±.22, p = .092). Caucasian males were younger with higher cognition scores than Caucasian women and African American males were younger with lower scores than African American females. Participants qualifying for referral (18 or 26%) were significantly older than those who did not (74.4 vs 70.0, p&lt;.05). Of 11 participants offered referrals, all Caucasians (3) declined and 5 of 8 African Americans (62%) accepted. Regression analysis determined that Mini‐Cog™ scores were associated with older age (β* = ‐0.255, SE = 0.02, p&lt;.05) and being African American (β* = ‐0.261, SE = .344, p&lt;.05) but not with sex, ethnicity, or living alone.ConclusionResults show that 25% of participants were identified with previously undetected cognitive impairment and that trained social service providers can effectively administer the Mini‐Cog™ instrument to assess cognitive impairment. Large scale studies are needed to further evaluate use of the Mini‐Cog™ instrument in early detection of cognitive impairment in minority and economically vulnerable older adults in non‐clinical settings.

Early Identification of Cognitive Impairment: Utility of the Mini-Cog in Non-Clinical Settings.

While we currently cannot cure Alzheimer's disease or change the course of the disease, there are advantages to early detection. Routine, evidence based, brief cognitive screens offer destigmatized opportunities for diagnosis and improve the possibility of early identification of cognitive impairment. This community-based participatory research project evaluated the use of the Mini-Cog™ instrument to detect cognitive impairment in vulnerable community-dwelling older adults when administered by trained social services providers. Over 9months, a case manager screened 69 clients ages 65 to 94 (mean 74.67) who met inclusion criteria for the pilot; 84.1% were female, 53.6% were Black, 26% were living with undetected cognitive impairment. Although participants agreed to Mini-Cog™ screening, two-thirds with Mini-Cog™ scores indicating cognitive impairment refused referrals for further evaluation. Future interventions should reduce stigma by educating the public about dementia and engaging members of racial and cultural communities in outreach.

Psychiatric liaison team memory pathway: does it achieve the standards set out in NICE clinical guideline 97?

AimsEarly assessment, diagnosis and management for people living with dementia is essential, both for the patient and their carers. We recognised delays in established local pathways when patients had unplanned acute hospital admissions preventing them from attending memory diagnostic appointments. The Psychiatric Liaison Team (PLT) Memory Pathway was introduced as we had the skills and expertise to resume the process and to find new undetected patients.Our aim was to determine how well the newly implemented PLT Memory Pathway follows the standards outlined in the National Institute of Health &amp; Care Excellence (NICE) Clinical Guideline 97 (CG97): Assessment, management and support for people living with dementia and their carers.MethodA retrospective analysis of all PLT referrals from July 2018 to February 2020 (20 months) was performed to identify patients on the community memory pathway and those with possible undetected cognitive impairment. Data were collected from electronic patient records which included demographics, primary and collateral history, cognitive testing and imaging, dementia type among others. Results were analysed using Microsoft Excel.Result41 patients were included (59% female). 80% of patients were referred for memory problems or confusion. 63% had previous referrals to a memory service and was on the community memory pathway at the time of the referral. 34% were on anticholinergic medication but in only 14% were this documented as reviewed. 100 % were offered and had head imaging. A finding worthy of note was the absence of any from the ethnic minority background. 63% of patients were given a memory diagnosis and 34% had anti-dementia medication started. Patients’ families were made aware of the diagnosis in 83% of cases, due to the absence of next of kin details in the patient record. Primary Care was made aware in 100% of cases; post-diagnostic support was 100%.ConclusionThe PLT is well placed to bridge the service gap between the acute care trust and established community memory services when dealing with patients with dementia. A dedicated Memory Pathway has helped to close this gap and adherence to NICE CG97 standards was good, but there is room for improvement. A particular focus will be on improving documentation of anticholinergic medication review and exploration for the absence of ethnic minority patients. Aiming to achieve 100% family involvement is also recommended.This study has been submitted to the Royal College of Psychiatrists' Faculty of Old Age Annual Conference 2021.

Brain Health-Curbing Stroke, Heart Disease, and Dementia: The 2020 Wartenberg Lecture.

There is no health without brain health, which is threatened by rising curves of stroke, ischemic heart disease, and dementia (the triple threat). The fastest growing and intractable threat has been dementia. Focusing on finding a drug to stop Alzheimer disease has yielded growing knowledge but no treatments, partly because in the elderly, cognitive impairment results from multiple interactive pathologies aggravated by fragility and tempered by resilience on the advancing background of aging. The concept of vascular cognitive impairment (VCI) cuts pragmatically through this complexity. VCI is any cognitive impairment caused by or associated with vascular factors. It spans the spectrum of undetected cognitive impairment to full-blown dementia. The vascular component represents the only major current, treatable, and preventable contributor to dementia and offers the possibility of delaying, mitigating, or preventing more dementias in the near future. The triple threat conditions share the same protective and treatable risk factors and can be prevented together. The approach needs to be comprehensive, identifying all relevant environmental, socioeconomic, health care, and individual factors; targeted, as risks and protective factors differ among populations and individuals; and and investment valued, yielding worthwhile returns in terms of money, effort, or time. The World Stroke Organization's proclamation calling for the joint prevention of stroke and potentially preventable dementias has been endorsed by 23 international, regional, and national brain and heart organizations, including the American Academy of Neurology. We need to develop joint prevention programs to curb the triple threat. Millions of brains depend on it.

A Path to Early Diagnosis of MCI and Dementia: Integrating myMemCheck Into the Primary Care Workflow

Barriers to the early detection of mild cognitive impairment (MCI) and dementia can delay diagnosis and treatment. myMemCheck® was developed as a rapid free cognitive self-assessment tool that can be completed in the practice setting or at home to identify older adults that would benefit from a more comprehensive cognitive evaluation for MCI and dementia. Two prospective cross-sectional studies (N = 59; N = 357) were conducted to examine the psychometric properties and clinical utility of myMemCheck®. myMemCheck® evidenced adequate reliability (test-retest, r = 0.67) and strong construct validity (η2 = 0.29, discriminating normal, MCI, dementia). Receiver operating characteristic analysis evidenced an optional myMemCheck® cut score for identifying older adults with MCI or dementia (sensitivity = 0.80, specificity = 0.67, positive predictive value = 0.91, negative predictive value = 0.43). myMemCheck® explained 25% of cognitive status beyond basic patient information. We provide specific suggestions for integrating myMemCheck® into practice to optimize workflow. Study results are further interpreted in the context of two national online surveys (healthcare professionals, N = 181; consumers, N = 1740). Healthcare professionals widely agreed on the need (94%) and importance (86%) of cognitive self-assessments. Public demand for cognitive self-assessment was confirmed by consumers who trialed myMemCheck® as part of their survey participation—86% agreed on the need for a tool like myMemCheck®. Mixed methods findings suggest that myMemCheck® could fast- track the diagnostic process, facilitate appropriate referrals for cognitive and neuropsychological evaluation, reduce assessment burden in healthcare, and prevent negative outcomes associated with undetected cognitive impairment.

A path to early diagnosis of mild cognitive impairment and dementia: validity and reliability of the myMemCheck® self-administered screening tool.

Barriers to the early detection of mild cognitive impairment (MCI) and dementia can delay diagnosis and treatment. myMemCheck® was developed as a rapid free cognitive self-assessment tool that can be completed at home to identify older adults that would benefit from a more comprehensive cognitive evaluation. Two prospective cross-sectional studies were conducted to examine the psychometric properties and clinical utility of myMemCheck®. In Study 1, participants were independent living residents referred to an outpatient memory clinic (N = 59); older adults in the community and post-acute nursing home residents (N = 357) comprised Study 2. Psychometric analyses were performed on cognitive and psychological testing data, including myMemCheck®. myMemCheck® evidenced adequate reliability and strong construct validity. Receiver operating characteristic analysis evidenced an optional myMemCheck® cut score for identifying older adults at risk for MCI or dementia. myMemCheck® explained 25% of cognitive status beyond basic patient information. myMemCheck® may help fast-track the diagnostic process, facilitate appropriate referrals for cognitive and neuropsychological evaluation, reduce assessment burden in health care and prevent negative outcomes associated with undetected cognitive impairment.

EARLY IDENTIFICATION OF COGNITIVE IMPAIRMENT AMONG VULNERABLE OLDER ADULTS LIVING AT HOME

African Americans are twice as likely as Caucasians to develop Alzheimer’s disease and related dementias (AD/D), are at greater risk of frailty if they have AD/D, and are less likely to seek a diagnosis before experiencing a crisis. This collaborative community-based project aimed to evaluate the processes and outcomes of adding a Mini-Cog© screening to existing Area Agency on Aging (AAA) assessments performed by a neighborhood advisor in a lower-income African American neighborhood in a mid-sized northeastern city. AAA clients receive initial in-home screenings to assess their need for income-related services to help them continue living safely in the community, but are not screened for potential cognitive issues that may exacerbate or be masked by the very conditions that AAAs aim to address. This pilot was designed to introduce a mechanism for the early identification of previously undetected cognitive impairment, provide referrals for comprehensive cognition screening at a Center of Excellence for Alzheimer’s Disease (CEAD), and increase access to needed health and community support services. We hypothesized that adding the Mini-Cog© to existing AAA assessments would increase the early identification of vulnerable older African Americans with or at risk of AD/D. Process outcomes included challenges encountered when engaging community caregivers on the project team, learning to interpret Mini-Cog© results, the labor-intensive nature of scheduling Mini-Cog© assessments with existing clients, addressing client stigma and fear of AD/D, and client resistance to comprehensive testing. This presentation reviews process and outcome evaluation data from the pilot, and discusses implications for expanding the intervention.

Normative Data that Does Not Exclude Participants with Mild Cognitive Impairment Results in Lower Than Expected Memory Impairment Rates, Particularly in Females

Abstract Objective Mayo’s Older Adult Normative Studies (MOANS) have served as an important resource for clinicians for three decades. Data collection was completed prior to the development and widespread use of Mild Cognitive Impairment (MCI) as a construct. Therefore, a portion of individuals included in the MOANS normative studies likely had undetected cognitive impairment. Method The Mayo Clinic Study of Aging (MCSA) is a population-based study of cognitive aging among Olmsted County, Minnesota, residents that began in October 2004. We applied age-adjusted MOANS norms (Ivnik et al., 1992) for the Auditory Verbal Learning Test (AVLT) long delay recall to cognitively unimpaired participants age 56 or older in the MCSA (N = 3,603). We used 1-sample tests of proportions comparing observed impairment rates to impairment rates expected based on a normal distribution of performance. Results Results showed that a significantly lower than expected number of participants demonstrated impaired delayed recall based on MOANS norms (all p’s &lt; .001). Using a lenient cut-off (&lt; -1 SD), only 7.3% of participants demonstrated impaired performance (vs. 15.9% expected), and this was more pronounced for females (3.5% impaired) relative to males (11.1% impaired). Further, only 0.6% of participants demonstrated impaired performance at a cut-off of &lt; -2 SD, and no participants aged 80-91 reached this cut-off (2.3% expected). Conclusions Results suggest that the sensitivity of the original MOANS norms is lowered by likely inclusion of individuals with MCI, particularly in females. Updated normative data for the AVLT that exclude individuals with MCI and adjust for sex are needed.

Validation of the O3DY French Version (O3DY-F) for the Screening of Cognitive Impairment in Community Seniors in the Emergency Department.

It is recommended that older patients undergo systematic mental status screening when presenting to the emergency department (ED). However, the tools available are not necessarily adapted to the ED environment, therefore, quicker and easier tools are needed. The purpose of this study is to validate the Ottawa 3DY-French (O3DY-F) Scale as a screening tool for delirium and cognitive impairment in a French-speaking cohort. This multicenter prospective study was conducted in four hospitals across the province of Quebec. Inclusion criteria were: age ≥ 65years, ED stay ≥ 8h, awaiting admission to a care unit, and independent or semi-independent in their daily living activities. Cognitive status was assessed during the initial interview using the Telephone Interview for Cognitive Screening-modified (TICS-m) and the O3DY-F scale. Comparisons were made between the O3DY-F and the TICS-m and Confusion Assessment Method (CAM) to assess the sensitivity and specificity of the O3DY-F for the detection of cognitive impairment and delirium. A total of 313 patients were included in this study, 139 of which had a positive O3DY-F. When compared with the CAM, the O3DY-F had a sensitivity of 84.2% (95% confidence interval [CI] 60.4-96.6) and a specificity of 58.2% (95% CI 52.3-63.9) for the detection of prevalent delirium. The O3DY-F had a sensitivity of 76.2% (95% CI 66.7-84.8) and a specificity of 67.6% (95% CI 61.0-73.6) for cognitive impairment (defined as a TICS-m<27). The O3DY-F is a useful and effective tool to screen for delirium and undetected cognitiveimpairment among a French-speaking cohort in the ED.

Getting clocked: screening for TBI-related cognitive impairment with the clock drawing test

ABSTRACTPrimary Objective: Undetected cognitive impairment resulting from Traumatic Brain Injuries (TBIs), particularly the 75–95% classified as mild (mTBI), poses a significant public health challenge as untreated symptoms, can persist and cause lasting disability. These cognitive deficits are often missed by standard screening tests, creating a need for alternative cognitive screening tools. The Clock Drawing Test (CDT), a popular, brief cognitive screening instrument, was used to evaluate cognition in persons with TBI.Design: The effectiveness of the CDT was assessed on its own and in tandem with a validated computerised screening battery, including the Stroop Test, Symbol Digit Modalities Test (SDMT), and Paced Visual Serial Addition Test 2-second trials (PVSAT-2).Methods and Procedures: The clock drawing component of the Montreal Cognitive Assessment (MoCA) of 223 subjects attending an outpatient TBI clinic was scored using two different methods.Main Outcomes and Results: The CDT screened for cognitive impairment most effectively when scored using the Clock Drawing Interpretation Scale (CDIS). Cognitive impairment was detected in 19.4% of the elusive cohort of persons with mTBI.Conclusions: The results of this study suggest that the CDT is effective at screening for cognitive impairment in persons with TBI. The CDT could be a valuable supplementary tool in TBI clinics as well as an effective cognitive screening instrument in busy primary care settings.

LO57: Validation of the Ottawa 3DY in community seniors in the ED

Introduction: Cognitive dysfunction is getting more common in geriatric emergency department (ED) patients, as the number of seniors visiting our EDs is increasing. ED guidelines recommend a systematic mental status screening for seniors presenting to the ED. As the existing tools are not suitable for the busy ED environment, we need quicker and easier ways to assess altered mental status, such as the O3DY. The purpose of this study is to assess the effectiveness of the French version of the O3DY to screen for cognitive dysfunction in seniors presenting to the ED. Methods: This is a planned sub-study of the INDEED project, which was conducted between February and May 2016 in 4 hospitals across the province of Québec. Inclusion criteria were: patients aged ≥65, with an 8-hour ED stay, admitted on a care unit, independent or semi-independent in their activities of daily living. Exclusion criteria were: patient living in a long-term nursing facility, with an unstable medical condition, pre-existing psychiatric condition or severe dementia, a delirium within the 8-hour exposure to the ED. A trained research assistant collected the following data upon initial interview: socio-demographic information, cognitive assessment (TICS-m), functional assessment (OARS) and delirium screening (CAM). The O3DY was also administered at initial interview and during patient follow-ups, as well as the CAM. Results: This study population was composed of 305 participants, of which 47.7% were men. Mean age was 76 years old (SD: 10.8). Nine of these participants had a previous history of dementia. 151 of these participants (47,04%) had a negative O3DY and 154 (47,98%) a positive O3DY at the initial encounter. When compared to the CAM, the O3DY presents a sensitivity of 85.0% (95% CI [62.1, 96.8]) and a specificity of 57.7% (95% CI [51.8, 63.6]) for prevalent delirium. When compared to the TICS, the O3DY presents a sensitivity of 76.7% (95% CI [66.4, 85.2]) and a specificity of 68.1% (95% CI [61.3, 74.3]) for cognitive impairment. The combined measure presents a sensitivity of 76.7% (95% CI [66.6, 84.9]) and a specificity of 68.4% (95% CI [61.7, 74.5]). Conclusion: A negative result to the O3DY indicates the absence of prevalent delirium or undetected cognitive impairment. The O3DY could be a useful tool for the triage nurses in the ED.

D2-4: Failure on Cognitive Screening Predicts Increased Healthcare Utilization

Background/Aims Most physicians fail to diagnose dementia until the moderate-severe stages. Cognitive screening for dementia in the asymptomatic population is not routinely performed due to the absence of evidence showing improved health outcomes. HealthPartners has piloted the use of the Mini-Cog as a standardized screening tool for cognitive function in patients aged 65 and older in order to assess the impact of undetected cognitive impairment on chronic disease management and healthcare utilization.

A Program to Improve Detection of Undiagnosed Dementia in Primary Care and Its Association with Healthcare Utilization

Alzheimer's disease and related dementias are common and costly, with increased healthcare utilization for patients with these disorders. The current study describes a novel dementia detection program for veterans and examines whether program-eligible patients have higher healthcare utilization than age-matched comparison patients. Using a telephone-based case-finding approach, the detection program used risk factors available in the electronic medical record (EMR) and telephone-based brief cognitive screening. Holding illness severity constant, dementia detection and healthcare utilization were compared across age-matched groups with and without program risk factors. Five Veterans Affairs Healthcare Network Upstate New York primary care clinics. Veterans aged 70 years and older. EMR data and the Charlson comorbidity index. Program-eligible patients (n= 5,333) demonstrated significantly greater levels of medical comorbidity relative to comparison patients and were on average more than twice as likely to be admitted to the hospital. They also had nearly double the number of outpatient visits to several services. Similar patterns were seen in those who screened positive on a brief cognitive measure, compared with those who screened negative. A novel program using EMR data to assist in the detection of newly diagnosed dementia in a clinical setting was found to be useful in identifying older veterans with multiple comorbid medical conditions and increased utilization of hospital and clinic services. Results suggest undetected cognitive impairment and dementia may significantly contribute to healthcare utilization and costs of care in older veterans.

Undetected Cognitive Impairment and Decision-Making Capacity in Patients Receiving Hospice Care

: Cognitive dysfunction is common in patients with advanced, life-threatening illness and can be attributed to a variety of factors (e.g., advanced age, opiate medication). Such dysfunction likely affects decisional capacity, which is a crucial consideration as the end-of-life approaches and patients face multiple choices regarding treatment, family, and estate planning. This study examined the prevalence of cognitive impairment and its impact on decision-making abilities among hospice patients with neither a chart diagnosis of a cognitive disorder nor clinically apparent cognitive impairment (e.g., delirium, unresponsiveness). : A total of 110 participants receiving hospice services completed a 1-hour neuropsychological battery, a measure of decisional capacity, and accompanying interviews. : In general, participants were mildly impaired on measures of verbal learning, verbal memory, and verbal fluency; 54% of the sample was classified as having significant, previously undetected cognitive impairment. These individuals performed significantly worse than the other participants on all neuropsychological and decisional capacity measures, with effect sizes ranging from medium to very large (0.43-2.70). A number of verbal abilities as well as global cognitive functioning significantly predicted decision-making capacity. : Despite an absence of documented or clinically obvious impairment, more than half of the sample had significant cognitive impairments. Assessment of cognition in hospice patients is warranted, including assessment of verbal abilities that may interfere with understanding or reasoning related to treatment decisions. Identification of patients at risk for impaired cognition and decision making may lead to effective interventions to improve decision making and honor the wishes of patients and families.

&lt;b&gt;Screening for Undiagnosed Cognitive Impairment in Homebound Older Adults&lt;/b&gt;

To screen for undetected cognitive impairment in homebound elders receiving home health care services. A cross-sectional study of adults 60 years of age and older receiving visiting nurse services. A pharmacist administered the Mini-Cog, a rapid screening test for cognitive impairment, during the enrollment home visit. Participants' homes. A consecutive sample of 100 homebound adults, 60 years of age or older with no previous diagnosis of dementia, Alzheimer's disease, or other cognitive impairment. Percentage of participants scoring in the likely impaired range (screen failure) on the Mini-Cog. Seventeen percent of persons with no prior diagnosis of dementia or cognitive decline failed the Mini-Cog. Rates of undetected cognitive impairment are substantial in homebound elders receiving care from a visiting nurse service. The home health setting represents an important point in the continuum of geriatric care for detection of cognitive impairment. Future work should define the types and trajectories of cognitive impairment detected in home care patients by simple screens such as the Mini-Cog and test ways to integrate this knowledge into longitudinal treatment plans across settings of care.

Self-reported severe memory problems as a screen for cognitive impairment and dementia

Undetected cognitive impairment (CI) and dementia are important clinical and epidemiological problems. This study addresses the effectiveness of using a single self-reported measure of severe memory problems (SMP) as a screen for CI and dementia. For the purposes of the study, 3220 elderly women participated in a mailed Health Survey Questionnaire and telephone interviews. Cognitive scores derived from the Telephone Interview for Cognitive Status–modified (TICSm) were calculated. Based on a multi-stage assessment strategy, all subjects were classified in one of three status categories: dementia, CI, or unimpaired. The SMP question was suggestive of cognitive problems in the majority of responders. t-tests found affirmative responders scored much lower on the cognitive test than negative responders. The SMP question had a sensitivity of .24 and a specificity of .99 for screening CI and dementia. While other assessment measures are needed, the SMP question is highly suggestive of CI and may serve as a first-stage screen in clinical and research settings.

Evaluation of Cognitive Function in Aviators

The FAA is concerned that flight-safety could be compromised by undetected cognitive impairment in pilots due to conditions such as substance abuse, mental illness and neuropsychological problems. Interest has been shown in the possibility of adding a brief “mini mental exam”, or a simple automated test-battery to the standard flight medical to screen for such conditions. This paper reports an empirical evaluation of four such tests, focusing upon a prototype version of an automated screening battery, SPARTANS (Simple Portable Aviation Relevant Test-battery and Answer-scoring System).

Recognition of cognitive impairment in primary care outpatients.

We evaluated 100 primary care outpatients for signs of cognitive impairment using the Mini-Mental State Examination (MMSE). The 23 subjects scoring abnormal values (less than 24/30) were found to be cognitively impaired. Seventeen had previously undetected cognitive impairment, while six had prior diagnoses consistent with cognitive impairment. Independent psychiatric evaluation identified these 23 outpatients as cognitively impaired, confirming the MMSE as a reliable, rapid instrument for cognitive assessment.